A doctor shares what his patients’ last moments have taught him
— William Dunbar (1465–1530), translation by T.E. Holt, M.D.
"Dude! You totally Melvined Death!"
— Bill & Ted's Bogus Journey (1991)
My first day of medical school was a series of inspirational talks. The tone, set by the anesthesiologist who led off, was lighthearted. His subject was "Everything you will ever need to know about medicine." This turned out to be just three things, which he had us all recite: Air goes in and out. Blood goes round and round. Oxygen is good. Just keep these in mind, he said, and you'll be okay.
By the end of the day, we were as blank as the huge whiteboards at the front of the room. Within the next 24 hours, these would start filling up with diagrams of cell-transport mechanisms, cartoons of developing embryos, maps of the brachial plexus. But on that first day, the lectures were so inconsequential that only one speaker bothered to write anything down. This was a pathologist who also wanted to reduce medicine to its essentials. He scrawled a single word on the board: DEATH.
Just avoid this one thing, he said, and we'd be okay.
The word stayed up there on the whiteboard the rest of the day. I waited for someone to notice and wipe it away, but no one did. It was gone the next morning, replaced by the Krebs cycle, that happy intracellular Rube Goldberg mechanism that keeps us all alive, whether you can diagram it from memory or not, thank God.
Whoever scribbled the Krebs cycle in place of that single stark word gave us our real orientation to medicine. Despite death's modest appearance that first day, what we were really learning wasn't "Don't Fear the Reaper" so much as "Don't See the Reaper."
We don't like to find that word staring down at us from the wall. If we do, we'll hang it on somebody else, shrouding it behind a screen of medical abbreviations, and then we'll be gone. The word's still there — it follows us, of course, as the moon follows a moving car — but as long as we don't have to keep looking at it, we're okay.
The problem is, death keeps looking at us. When I'm forced to think about this, what I see most clearly are the faces of patients at the moment they recognized the incredible fact that they were going to die soon. This is what I can't forget: the look they had as they read the writing on the wall like Belshazzar did at his feast in the Bible story, faced at the height of his power with the message that he was about to die. Just what people see as they read that message is, I suspect, the most important fact about death. I know that fact escapes my grasp, but I keep reaching for it, all the same.
He was 18 years old with cystic fibrosis. By unspoken agreement, we had left him until last on morning rounds, because overnight the lab had analyzed his blood and cultured Burkholderia cepacia — an organism that flourishes in the pus that overwhelms the lungs in end-stage cystic fibrosis. It's notoriously resistant to antibiotics. (It's been found growing on penicillin.) Once B. cepacia escapes the lungs and enters the bloodstream, death is inevitable: sepsis, circulatory collapse, multiorgan system failure, the end.
After a muttered conversation in the hallway, we edged into the room. I was nervous: I was going to have to tell this kid he was dying. He was awake, sitting up in bed. The room was dark. It had that lived-in look CFers cultivate — posters, clothes strewn everywhere, a game console flickering on idle. A wasted-looking father slumped in the corner chair. The patient watched us file in. When I saw the expression on his face, my anxiety about what I was going to say seemed suddenly unimportant.
He knew. He already knew. He barely listened as I reported what we had learned from the lab. Then there was silence. He looked back at me as if I weren't there and said, "I'm going to die, aren't I?"
It wasn't really a question, the way he said it. My answer was as irrelevant as everything else that we had left to offer him. The attending stepped in and started talking, but I could tell the patient wasn't listening.
A year or so later, I was the resident on the oncology service, responsible for two dozen or more patients, all of whom were doing badly. Doing badly with cancer means terrible things: organs malfunctioning as tumors squeeze them off, pain that soaks up morphine like water, treatments with a list of possible side effects that includes death.
Into this substation of hell one day walked a strong man in his early 40s, looking about as healthy as a man can look, though perhaps a little pale. Earlier that day, a blood test had revealed a swarm of misshapen, blue-stained cells that should have been functioning parts of his immune system but instead were leukemia. He was in what they call "blast crisis"; our job was to help him survive the night so he could start chemotherapy in the morning.
Over the course of that night, his blood levels of oxygen started to drop, his left eyelid developed a droop, and I had to explain to him that if I didn't insert this honking big catheter into his femoral vein, he wasn't going to live to see the morning.
I could see him change. He had walked in as a functioning adult. He had asked intelligent questions before signing the consent form. He had been calm, helpful, determined. He had a pleasant smile. That was until about 4 p.m. As things started to unravel, he became at first bewildered, then querulous, and then, as the leukocytes started clogging the capillaries of his brain, confused. He tried not to groan as I probed for that vein in his groin, but despite the lidocaine, when I sliced into his skin to widen the opening for the catheter, he screamed. After that he settled into a silence that deepened throughout the night.
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